A couple of weeks ago my friend fell off his bike and smacked his head. He got a small brain bleed and had to spend the night in ICU. Like most healthcare visits there were some hiccups – they didn’t contact me until 5 minutes after visiting hours ended, there weren’t drug orders (I swear he saw death coming for him while we waited for a script), and, of course, the doctors rounded at 6AM and we had to wait nine hours to find out his status and disposition (home!).

But what really bugged me? The medical record release process.

To ensure continuity of care we need his records from the hospital for a neuro followup on Friday. I figured it’d be pretty standard -- just have the specialist’s office call and fax over a request. I wanted to make sure his records made it so I double-checked the process this morning. They told me they wouldn’t release the records without an original signature. No faxes allowed. We could mail it in or come in person.

Ok, fine. Instead of making him get in a car (makes him sick) or do a lot of running all over town, I had him send me his power of attorney. See, there's loophole in their “original” signature thing – as his power of attorney, I can make his decisions (or, in this case, get some copies made) with my original signature. No problem- I sent him a standard health POA, he signed it, got it witnessed, sent it back, and I went to the hospital in person to get some records. The interaction went something like this:

Records Clerk #1: Can I help you?

Me: I need some medical records sent from here to Kaiser.

RC #1: Are you the patient?

Me: No, but I’m his power of attorney. Here’s the paperwork.

**RC#1 peruses the paperwork**

RC #1: Let me check with someone else.

**RC#1 talks to RC#2**

Records Clerk #2: Where’d you get these signatures?

Me: I had him sign it and send it to me.

RC #2: This isn’t his signature.

Me: Yes it is.

RC #2: It doesn’t match the one we have on file.

Me: His brain was bleeding when you got that. This is his real signature.

RC#2: Who are you?

Me: His friend.

RC #2: Just a friend? And he gave you Power of Attorney?

Me: Yes.

RC#2: You printed this off the internet. This isn’t a Power of Attorney.

Me: He’s an attorney and I have a master’s in health administration. This is what we do. It's legal.”

RC#2: Let me check with my supervisor.

Me: Ok.

Supervisor: Who are you?

Me: His Power of Attorney.

Supervisor: No, who are you?

Me: His friend… **looks at me like I’m crazy**… I’m his person.

Supervisor: His significant other?

Me: Sure.

Supervisor: Ok. **looks at the POA** This isn’t notarized.

Me: If you have two witness signatures, you don’t have to get it notarized.

Supervisor: …I just don’t know enough about this and my Supervisor isn’t in. Why don’t you have them fax us to fax them?

Me: That’s what we tried to do this morning. Your office said I had to come in person!

Supervisor: Well, here’s our fax number… we’re just really careful.

After that I called Kaiser. Got the right form. Filled it out with the wording to make sure the records get sent from provider to provider. Sent it to him, had him sign it and fax it in. A fifteen minute process that, because of the runaround, took three hours. Still waiting on them to confirm receipt. Despite this hospital being on track to achieve Meaningful Use, they said it may take 7-30 days to get his records. Fingers crossed, that CAT scan makes it to neurology on Friday…

When there are too many hoops to jump through - like needing to provide a original signature - inefficiencies abound. When people are uninformed - like insinuating "just a friend" isn't the legitimate POA- there's a real liability issue. Look, I want medical records to be private and secure. I understand that there are real consequences for data breaches and HIPAA violations. I get that creating information from data can be difficult and health literacy is a real concern. But there are ways to mitigate these issues. HIPAA fears should never be an excuse for disrupting the continuum of care.

As you know - Meaningful Use Stage Two posted this week! Whoo hoo! There were a few changes from stage one and but from where I sit, it looks like things are aligned rather well. I did a summary of the NPRM (copy/pasted below (download it with pretty graphics here)), and also distributed by HIMSS. It's a pretty complete summary and highlights the differences between stage one and two. The only thing I didn't consider was the incentive/penalty structure. I'm not about to get into the business of telling people where the money's at!

Summary

The 2009 American Recovery and Reinvestment Act (ARRA) authorized incentive payments for the Meaningful Use of Electronic Health Records (EHR) through Medicare/Medicaid. This document is a high-level summarization highlighting the differences between the objectives in the Notice of Proposed Rule Making for Stage Two[i] and the Stage One Final Rule.[ii] CMS is “soliciting public feedback on several mechanisms for electronic CQM reporting, including aggregate-level electronic reporting group reporting options; and through existing quality reporting systems.” Stage Two:

If a provider submits exclusion criteria for 1 of their menu sets, they are also attesting that they meet the exclusion criteria for all of the menu objectives that they did not select.

A Certified EHR must be used for at least 50% of a provider’s population over the entire reporting period. If the EP practices at multiple locations, this will include only patients seen at locations with certified EHRs.

Denominators will be one of four things:

Unique patients seen by the EP (stratified by age or previous office visit) or EH/CAH (stratified by age).

Number of Orders (medication, labs, radiology, imaging, and procedures).

EH/CAH Inpatient bed days: admission day and each of the following full 24-hour periods during which the patient is in the inpatient dept of the hospital.

EPs will have latitude to include or not include telemedicine, minimal consulting services, and double counting (counting patient for both NP/PA and EP in same office).

Objectives

Changes to Stage One Criteria:

This Stage Two rule alters some Stage One criteria – these changes will be optional in 2013 and required in 2014 (except otherwise noted):

CPOE: more than 30% of medication orders created by the EP/authorized providers at a EH/CAH are recorded using CPOE.

Vital Signs: addition of alternative age limitations (blood pressure will be only applicable for those over the age of three, while height/weight is for all ages) and exclusions (if all vitals, blood pressure, height/weight do not impact practice, provider does not have to record).

Exchange Key Clinical Data: Eliminated. Effective 2013.

Report CQM: Eliminated. Effective 2013.

Patient Electronic Communication: Same as Stage Two.

Public Health: Adds “except where prohibited” to language. Effective 2013.

Differences between Stage One and Stage Two Criteria:

All Stage One Menu Set criteria are now in the core set, with the exception of two which will remain in the menu set: submitting syndromic surveillance data (EPs) and recording advanced directives (EH/CAH).

State Flexibility: States will continue to be able to specify transmission of data and public health measures so long as it does not require EHR functionality above and beyond that which is included in the ONC EHR certification criteria.

Other measures were Consolidated/Eliminated, including:

Consolidated/Eliminated Measures

Consolidated/Eliminated Measure

Logic

Drug/Drug and Drug Allergy Checks

Combined into CDS.

Report CQM to CMS or States

Completed with QMS reporting section of MU and not necessary as an objective.

Drug-Formulary Checks

Combined into eRx

Maintain an up-to-date problem list of current and active diagnoses.

Combined into Transition of Care.

Maintain active medication list.

Maintain active medication allergy list.

Provide patients with an electronic copy of their health information.

Combined with objectives for online viewing and downloading

Provide patients with an electronic copy of their discharge instructions.

Capability to exchange key clinical information.

Removed for Stage 2. Considering options for Stage 1. Actual use case is more beneficial.

Use computerized provider order entry (CPOE) for medication, laboratory and radiology orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines to create the first record of the order.

Core, 60%Numerator: CPOE OrdersDenominator: All orders

Core, 30%

Providers with less than 100 orders.

Must be used the first time the order is placed and before any action can be taken on the order.This measure has changed from “% of patients with one order in their EHRs”

Less than 100 Rx’s writtenNo electronically connected pharmacy within 25 miles

Does not include controlled substances for schedules II-V as many vendor offerings lack the required DEA specifications. Will revisit for MU III.In 2015 the MIPAA eRX program will be phased out for MU.MU Stage One “compare to a drug formulary” menu objective is rolled into this one.

Record the following demographics as structured data

Preferred language

Gender

Race

Ethnicity

Date of birth

Date and preliminary cause of death in the event of mortality (EH/CAH Only)

Core, 80%Numerator: Patients with all demographic information recordedDenominator: All Patients

Core, 50%

If the patient refuses to give the information the provider can count that patient in the numerator.

Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach.

Generate at least one report listing patients of the EP, eligible hospital or CAH with a specific condition.

Menu, 1 list

EP Only: Use clinically relevant information to identify patients who should receive reminders for preventive/follow-up care.

Core, 10%Numerator: Number of patients in the denominator who received a reminder during the EHR reporting periodDenominator: Unique patients who have an office visit with the EP in the 24 months prior to the EHR reporting period

Menu, 10%

No office visits in the 24 months before the reporting period

Different from stage one – requires the use of EHR to identify appropriate reminders instead of just sending reminders based on patient preference.

EH/CAH Only: Automatically track medications from order to administration using assistive technologies in conjunction with an electronic medication administration record (eMAR).

Core, 10%eMAR is implemented and in use for the entire EHR reporting period in at least one ward/unit of the eligible hospital or CAH.

N/A, New Measure

A ward or unit is defined having unique staff, patient population, geographic location or function from other IP/ER Departments.

Policy Priority: Engage patients and families in their health care

EP Only: Provide patients the ability to view and download their health information within four business days of the information [labs, imaging, etc] being available to the EP.

Core, 50%Numerator: Patients who can access their informationDenominator: Number of Unique Patients

Core, 50% within 4 days

Providers who provide 50% of their care in areas where 50% of their patients do not have at least 4 Mbps broadband availability

Core, 10%Numerator: Patients who access/download/transmit their informationDenominator: Number of Patient Visits

N/A

EH/CAH Only: Provide patients the ability to view online and download information about a hospital admission within 36 hours of discharge

Core, 50%Numerator: Patients who can access their informationDenominator: Number of Unique Patients

New

50% of patients do not have at least 4 Mbps broadband availability

Core, 10%Numerator: Patients who access/download/transmit their informationDenominator: Number of Patient Visits

Medication Reconciliation is performed upon receiving a patient from another setting of care.Most accurate list of all medications that the patient is taking:

Name

Dosage

Frequency

Route

Core, 65%Numerator: Patients for which MR was performedDenominator: Patients received from another setting of care

Menu, 50%

It’s unlikely to be an automated process so the electronic exchange of information is not required.“another setting of care” is from outside the organization.

Any provider who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary care record for each transition of care or referral.

If there are no appropriate agencies/registries to receive the information.If the registry/agency doesn’t accept electronic submissions format/standard specified by ONC’s certification rules. If an HIE has been delegated to receive information on the agency/registry’s behalf this exclusion is not acceptable.Where prohibited, and in accordance with applicable law and practice.

Stage 3 will likely be bidirectional.

EH/CAH Only: Capability to submit electronic reportable laboratory results to public health agencies, except where prohibited, and in accordance with applicable law and practice.

EP Menu; EH/CAH Core: Capability to submit electronic syndromic surveillance data to public health agencies, except where prohibited, and in accordance with applicable law and practice.

Clinical Quality Measures

Many measures were put out in the NPRM, only a subset will be finalized.

EP CQM Measures: 125 Potential Measures

Two Options:

Option 1a: Select and submit 12 measures from the list of measures; one measure from each domain is required. If a provider’s EHR doesn’t include information for 12 measure, they must submit all of the measures that they can.

Select and submit 24 measures from a list of 49 measures (all 15 from Stage One are included); one measure from each domain is required.

Submit 24 CQM in a manner similar to the 2012 Medicare EHR Incentive Program Electronic Reporting Pilot (Medicare Hospitals Only).

Drug Management:

Antibiotics: Pneumonia, Perioperative

Asthma

Cardiology: AMI, HF,

Ischemic Stroke

Pneumonia (antibiotics)

VTE Prophylaxis

Disease/Condition Care:

Asthma

Cardiology: Heart Failure, AMI,

Immunizations: Pneumococcal, Flu

Ischemic Stroke

Labor/Delivery: hearing, elective births, surfactant, complications

Surgical: VTE Prevention, Antibiotics, Catheter, Hair Removal

Medical Practice:

Home Management Plan of Care

Emergency Department Throughput

PICU Pain Assessments

NICU temperatures

[1] Author’s Note: This summary was based upon publicly available knowledge and does not represent the view of the FDA, HHS, or ORISE. The author was not involved in writing this NPRM; any errors or omissions are solely the author’s. This summary was supported in part by an appointment to the Research Participation Program at the Center for Drug Evaluation and Research administered by the Oak Ridge Institute for Science and Education through an interagency agreement between the U.S. Department of Energy and the U.S. Food and Drug Administration. The author can be reached at jess.a.jacobs@gmail.com.

In 2004, President George W. Bush set a goal that by 2014 every American should have an electronic health record (EHR). October 1st 2010 marked the government’s foray into the 2011 Fiscal Year -- it is now T-3 years and counting. I have no doubt that every American will have an electronic health record by 2014. And if they don’t, well, they can have one of mine.

As a young person with a medical issue, I have access to upwards of 15 EHRs and their requisite patient portal access. Despite the prevalence of EHRs, I doubt the quality of my care is significantly better. See, my data is stuck in EHRs don’t talk to each other. A few months ago I found myself trying to get care at a well-respected, technologically savvy, teaching hospital. Having not been there before, I attempted to have my medical records sent from another electronically enabled medical center. This task proved impossible and I had to have my friends bring me my hot-pink binder of medical records, which, unfortunately, did not reflect my most recent notes. See, in schlepping my medical records from hospital-to-physician-to-hospital, I had missed a visit. Indeed, it is a pain to ensure that the records are complete, even though many of them originated in EHRs. After all, a paper printout of an EHR is still just paper printout. The point of this anecdote is that if I, a Masters student in Health Systems Administration, cannot figure out the system, neither can your grandmother. This process is not safe or efficient and frustrates providers and patients alike.

2009 estimates show good progress toward President Bush’s goal: 46% of hospitals and 44% of ambulatory providers indicated that they have an EHR. Unfortunately, like my story showed, “adoption” is not indicative of meaningful adoption. When these rates are examined again, fully functional, communicating, EHR systems account for only 1.5% of adoption in hospitals and 6% of adoption in ambulatory providers. I don’t deny that full, meaningful, adoption is difficult -- startup costs are immense, workflow issues prohibitive, the Return on Investment questionable. Anyway the picture is painted, adopting a fully functional EHR is seemingly impossible for all but the largest medical centers. Fortunately, President Obama’s thrown a curve ball with the American Reinvestment and Recovery Act of 2009. Through the Title VII: Health Information Technology for Economic and Clinical Health Act, ARRA promotes the adoption of Electronic Health Records, promising upwards of 20 Billion dollars in incentive payments for the Meaningful Use of EHRs as defined by the Office of the National Coordinator (ONC). Furthermore, it allocates funds to provide assistance in vetting EHR software choices, training workforces, and creating Health IT test-beds.

But these programs are just tools. Indeed, the first step to creating a continuously learning high performing health IT system is to take advantage of these tools and incentives to lay a solid EHR foundation which exchange can be built from. Second, it is time to spend energy not only on adopting EHRs but ensuring that we utilize them in patient centric ways. If patients aren’t engaged by their health information, what is the point? Sure, the physician has a complete record of care and is held responsible by mandatory quality reporting. Sure, with clinical decision support tools and ePrescribing, drug safety increases. But how does a patient know that these functionalities exist, let alone, that they are benefitting their health? If a provider cannot access an aggregated EHR at the point of care, again, what is the point?

Great strides have been made in integrating communities of care with electronic health information. Through the Patient Protection and Affordable Care Act, the Center for Medicare and Medicaid Innovation (CMMI) has been tasked with defining and creating Accountable Care Organizations. These organizations will likely be based off of the Geisinger/Kaiser model and pay based on a capitated system. But what is more important than their payment structure and commitment to provide comprehensive care is their continual commitment to innovation.
This commitment to innovation is exhibited by CMMI’s reception to mobile health technologies. The ability of EHRs to interface with remote medical devices will be groundbreaking. Take, for instance, a diabetic. Currently, a diabetic takes a blood glucose reading and records it by hand. These logs are often illegible and physicians do not have the time to page through them to identify trends. Currently the technology exists to link glucose meter readings to patient records electronically. This link ensures that readings are recorded correctly and allows for physicians to passively monitor a patient’s blood glucose, enabling them to take immediate action when levels fall outside a predetermined range. Furthermore, the system can remind a patient to check their blood sugar and allows the patient to track their progress via an online portal. This application is a prime example of how technology enables effortless patient communication and provider accountability. Pilot studies show that this kind of application is effective; indeed, it is correlated to a reduction of 5 points in blood glucose readings and a 1% reduction in HbA1c readings over a three-month period.

But this level of innovation is not possible so long as we believe that EHRs are simply static repositories of information. Until there is an open flow of information between providers and patients, this level of innovation will remain but a dream. Indeed, patients and providers alike must demand this kind of functionality be reimbursed by payors by proving the tool’s value through consistent utilization and better outcomes. I believe that we can move beyond this dysfunctional Health IT system and into one that is truly patient centered. Have I been drinking the proverbial kool-aid? Probably. But if that’s what gets me to think outside of the “EHR as savior” box and vocalize the need for the engaged exchange of medical information across the continuum of care, pour me another glass. Cheers.

Note: With this essay I won the distinction of being the 2011 NCHE Graduate Scholar.

Before I went to the reception I sent this picture to a friend telling them that I couldn't wear the "hooker heels" UNLESS I won. If you win you get to wear whatever non-totally-business appropriate shoes you want!

This is a covert shot I took as soon as I won and sent to my Grandma. Grandmas like images like that.